What Matters

Screening for microalbuminuria


So that we all may learn, I offer myself as an example. I freely admit that I have been following yearly urinary microalbumin in my patients with diabetes who are already on an ACE inhibitor or an angiotensin receptor blocker. Somewhere along the line, I learned that we were "supposed to" do this. Weak justification for clinical behavior, I know, but I also know I am not the only one doing this.

Further complicating this behavior is my lack of understanding about what to do with the results when I receive them.

Typical scenario: A patient has diabetes and is on an ACE inhibitor with persistent microalbuminuria. ... Now what? I have traditionally increased the dose to the highest tolerable level or planned to recheck the following year, hoping it will go away. Somewhere along the line, an annual microalbumin has been incorporated into performance measures and clinical algorithms. ACP to the rescue.

The American College of Physicians just published a clinical guideline on the "Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease" (Ann. Intern. Med. 2013 Oct. 22 [doi:10.7326/0003-4819-159-12-201312170-00726]).

One of the four guideline recommendations speaking to this issue is that the ACP "recommends against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme inhibitor or an angiotensin II–receptor blocker." Reviewed evidence suggests that ACE inhibitors or ARBs reduce the risk for end-stage renal disease (ESRD) and that there is no evidence that monitoring for proteinuria in patients on these medications improves outcomes for patients with chronic kidney disease (CKD).

The other guideline recommendations are to not screen for CKD in asymptomatic adults without risk factors for it, to select an ACE inhibitor or ARB in patients with hypertension and stage 1-3 CKD, and to select a statin to manage elevated low-density lipoprotein cholesterol in patients with stage 1-3 CKD.

How long it will take for clinical practice to catch up and remove this as a performance measure remains to be seen.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn. The opinions expressed are those of the author.

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